I talk a lot with different physicians about integrating NP/PA providers into their practice. I am frequently astonished by the level of reluctance, resistance and downright animosity from these physicians. Many times a doctor will have a medical “horror story” with the NP/PA playing the villain. One bad encounter or event seems to justify a complete rejection of the many positive attributes and contributions of these NP/PA providers, and negates the many studies that reveal comparable and safe care and outcomes. Besides I have a few “horror stories” of my own, and guess who the villains are?
I’m always mystified by this. I practice in a very supportive environment. This culture extends from the hospital leadership, both medical and nursing, which seems to understand what we do and values the care we provide, to my section leadership, to the consulting services, to the RNs I work with and most of all, to the patients to whom I provide this care. Rarely if ever do I get a “I need to talk to your attending” type interaction, or get a request to see a physician. But it hasn’t always been this way. Our program is very mature and it is easy to forget the bumps and bruises I, and all of my NP/PA colleagues, have experienced on this road. And I’ve had other clinical experiences, in other institutions, where I have had to swallow my outrage and anger at being treated like a second class citizen, or as a handmaiden, or worse, as a brainless robot acting completely on someone else’s orders.
But still I wonder: Why in this day and age does this type of attitude persist? Again, if you look at our numbers, we are here. We aren’t going anywhere. Our impact is only growing. And it doesn’t sound to me like this is only a territorial issue-despite the persistent positions of the AMA.
Whenever there are “issues” in a relationship, personal or professional, I’m a firm believer in a two party system. Rarely are these problems completely one-sided. We all have our part to play. And NP/PAs have a responsibility, a role in some of the long standing difficulties that sometimes exist with our physician colleagues. Check out this list:
1. Shift worker mentality: Ever since a doctor was toddling around in his doctor diapers he was told and taught over and over that the patient was HIS/HER responsibility, that no one else was responsible. This persistent culture of responsibility may make it hard for a physician to let go of some control. But this is totally compounded by NP/PAs who want to come in, see a patient, leave, but not really own the patient. These providers don’t want to be responsible for post discharge care, or decision making. They want to get in and get out. If this is you, you get out!
2. Flabby decision-making: How many times, when faced with a difficult clinical decision, did I want to immediately reach out to “mom or dad” and have them make a decision? It’s easy to be lazy, to avoid using the muscles of critical thinking and let the doctor do all the heavy lifting. Do NOT do this! You have a brain, you are educated, use both of those tools, actually take time to consider the clinical conundrum. Of course if after calculated thought a clear course remains foggy, reach out with glee to your attending. But walk the walk before you talk the talk.
3. The unspoken agreement: This is where the physician complains that the NP/PA doesn’t “do” what they were hired to do, and the NP/PA states that the physician won’t “let” them do what they were hired to do. Part of this may be a lack of understanding about the appropriate scope of practice for NP/PA provider. But often, both sides are actually perfectly happy with the NP/PA not actually working within scope of practice. Change is hard and painful, like giving birth, but when you are finished you have a bouncing, baby, NP/PA practice that will actually advance the care of patients in a positive way. Start the conversation and the pitocin!
4. Lack of consistent quality: Easy to say, but not easy to fix. Over and over again I have heard physicians tell me that they like PA/NPs “when they are good,” but that they have seen some bad ones. Part of this may be related to misunderstanding the needs, scope of practice and requirements for mentorship of new graduates and novice providers. Part of it also may be lack of quality and consistent programs. Experienced providers need to mentor our newbies and help hospitals and physicians understand the steepness of the learning curve.
5. Professional development: As an NP/PA provider you are a professional, your work is not just a job, it’s a career! Act like it! Start developing your career which includes asking, or demanding, the things you want and need from your profession/role, developing your skill set and knowledge base in step with your (hopefully) growing responsibilities, connecting and staying active within your professional organization, advocating for other members of your profession, communicating in a direct and powerful way with your physician colleagues. You are not a passenger in the canoe of your life. Grab an oar!
Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations.
In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.